Preserving Our Health Benefits: Changes to Sustain Comprehensive, Affordable and Dependable...

Preserving Our Health Benefits:

Changes to Sustain Comprehensive, Affordable and

Dependable Coverage

2

Agenda

• Why are our health insurance options changing?

• What’s being done?

• What are the new options?

• Questions and answers

3

Financial Challenges

Sources: State of Tennessee paid claim reports.

State of Tennessee Aggregate Health Care Costs (All Plans)

$646

,334

,552

$779

,950

,258

$858

,482

,304

$907

,430

,204

$990

,280

,191

$1,1

20,6

53,4

56

$1,1

99,8

69,8

26

$1,3

28,8

08,5

90

$1,3

76,5

82,4

73

$578

,284

,299

$748

,033

,379

$893

,977

,889

$962

,691

,295

$1,0

68,8

90,1

99

$1,1

03,5

12,3

31

$1,1

99,7

55,2

75

$1,3

02,4

16,8

25

$1,3

48,4

97,8

26

$-

$200,000,000

$400,000,000

$600,000,000

$800,000,000

$1,000,000,000

$1,200,000,000

$1,400,000,000

$1,600,000,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 Proj.

Total Expenses

Premium

4

Funding Health Benefits

• State is financially responsible for plan expenses

• State Group Insurance Program bank accounts contain premiums collected each month

• Those premiums pay member claims and plan administrative expenses

5

ParTNers for Health

• Preserve comprehensive, affordable, dependable benefits

• Members take a more active role in their health

• Reduce health care costs in the long term

• Members are rewarded with immediate savings

Our approach is based on the idea that our members, the State and our plans can partner to improve member health and manage costs. We all have a stake in this new approach.

6

New Health Insurance Options

Choose between Two Preferred Provider Organization (PPO) Options

Partnership PPO

Standard PPO

Choose between Four Premium Levels

• Employee

• Employee + child(ren)

• Employee + spouse

• Employee + spouse + children

All members will have the same choices and will make their choices during the Annual Enrollment Transfer Period in the fall.

Choose an Insurance Carrier

• BlueCross BlueShield of Tennessee

• CIGNA

7

PPO Options

• Partnership PPO

• Standard PPO

8

How a PPO Works

• PPO – Preferred Provider Organization

• Visit any doctor or hospital you want

• A “preferred” network of providers agrees to lower fees

• You pay less when you use a network provider

9

Choosing An Insurance Carrier

• BlueCross BlueShield of Tennessee

• CIGNA

• The carriers’ covered services, deductibles, co-insurance, co-pays, etc., are the same whether you choose BlueCross BlueShield of Tennessee or CIGNA.

• Although BlueCross and Cigna are current providers, the new networks are different.

10

Finding Your Doctor and Other Health Care Providers

• ParTNers for Health Call Center• 1-866-741-6464

• Insurance Carriers Customer Service• Blue Cross 1-800-558-6213 (Network S)• Cigna 1-800-244-6224 (Open Access Plus)

• Insurance Carrier websites• www.bcbst.com/FindADoctor (Network S)• www.cigna.com (Open Access Plus)

http://www.bcbst.com/FindADoctor

http://www.cigna.com/

11

Choosing Your Premium Level (Tiers)

• Employee Only

• Employee + Child(ren)

• Employee + Spouse

• Employee + Spouse + Child(ren)

Bottom line: The Partnership PPO premiums are lower than the premiums for the Standard PPO.

12

If Your Spouse Works for a Participating Employer

• Choose your Premium Level separately

• Choose your PPO option and insurance carrier separately

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Premiums for 2011: State Plan

Premium Level Partnership PPO Standard PPO

Employee Only $102.30 $127.30Employee + Child(ren) $153.45 $178.45Employee + Spouse $214.83 $264.83Employee + Spouse + Child(ren) $265.98 $315.98

Employee Share of Monthly Premiums

The State pays 80% of the total premium cost for active employees.

14

Your Insurance Carrier Choice Affects Your Monthly Premium Cost

• Carrier costs vary by region• BlueCross BlueShield of Tennessee is the

highest cost carrier in the West region.• CIGNA is the highest cost carrier in East and

Middle regions.

• If you select the highest cost carrier in your grand division, you pay a higher monthly premium• Employee Only: $10 more• Employee + Child(ren): $20 more• Employee + Spouse: $20 more• Employee + Spouse + Child(ren): $20 more

15

Comparing Your PPO Options

Partnership PPO

Rewards members for taking steps to get or stay healthy

Commitment to Partnership Promise is required

Standard PPO

No incentives for healthy behaviors

Members pay a greater share of costs

Both options cover the same services, treatments and products. However, under the Partnership PPO, when you take an active role in your health,

you will pay less.

16

How You Pay for Health Care Services

• Co-pays

• Co-insurance

• Annual Deductible

• Annual Out-of-Pocket Maximum

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Co-Pays

Benefits Effective January 1, 2011

Partnership PPO Standard PPO

In-Network Out-of-Network* In-Network Out-of-Network*

Preventive Care No charge $45 co-pay No charge $50 co-pay

Well Baby or Well Child Visits

No charge $45 co-pay No charge $50 co-pay

Primary Care $25 co-pay $45 co-pay $30 co-pay $50 co-pay

Specialty Care $40 co-pay $65 co-pay $45 co-pay $70 co-pay

Prescription Drugs (At Retail Pharmacy)

$5 co-pay generic

$30 co-pay preferred brand

$80 co-pay non-preferred brand

Co-pay for applicable tier plus amount over maximum allowable charge

$10 co-pay generic

$40 co-pay preferred brand

$90 co-pay non-preferred brand

Co-pay for applicable tier plus amount over maximum allowable charge

*Members are responsible for 100% of all out-of-network provider charges above the maximum allowable charge (MAC).

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Free Preventive Care

• Annual preventive care check-up offered to members at no cost

• Lab work covered at 100% after co-pay

• You need to visit an in-network provider for all preventive care services

Regular preventive care is one of the most important things you can do to stay healthy.

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Co-Insurance



In-Network Out-of-Network* In-Network Out-of-Network*

Inpatient Care (Including Mental Health and Substance Abuse)

You pay 10% You pay 40% You pay 20% You pay 40%

Advanced X-ray, Scans and Imaging


Occupational Therapy, Physical Therapy, Speech Therapy



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Maximum Allowable Charge (MAC)

• All services have a maximum allowable charge (MAC)

• Your share of co-insurance is based on the MAC

• If a provider charges more than the MAC, you pay the additional amount due

When you visit an in-network provider, you don’t have to worry about exceeding the MAC. In-network providers agree in advance to fees that

don’t exceed the maximum.

21

Annual Deductibles



Annual Deductible In-Network Out-of-Network* In-Network Out-of-Network*

Employee only $350 $700 $700 $1,400

Employee + Child(ren) $700 $1,400 $1,400 $2,800

Employee + Spouse $700 $1,400 $1,400 $2,800

Employee + Spouse + Child(ren)

$900 $1,800 $1,800 $3,600

You pay the annual deductible before co-insurance benefits kick in.


** No single family member will be subject to a deductible greater than the employee only amount. Once two or more family members (depending on the premium level) have met the total deductible, it will be met by all covered family members.

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Examples: Co-insurance and Deductibles

You Pay PPO Pays

1. Your annual deductible $350 $0

2. Co-insurance $125 (10% of $1,250) $1,125 (90% of $1,250)

Total $475 $1,125

Scenario 1: $1,600 charge for in-network inpatient hospital stay Charges do not exceed MAC

Scenario 2: $1,700 charge for out-of-network inpatient hospital stay Charges exceed MAC by $100

You Pay PPO Pays

1. Your annual deductible $700 $0

2. Co-insurance $360 (40% of $900) $540 (60% of $900)

3. Amount that exceeds MAC $100 $0

Total $1,160 $540

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Out-of-Pocket Maximums

The maximums limit how much co-insurance you’ll pay in any given year if you or a covered family member have a serious illness or injury.



Out-of-Pocket Maximum In-Network Out-of-Network* In-Network Out-of-Network*

Employee Only $1,350 $2,700 $1,700 $3,400

Employee + Child(ren) $2,700 $5,400 $3,400 $6,800

Employee + Spouse $2,700 $5,400 $3,400 $6,800

Employee + Spouse + Child(ren)

$3,500 $7,000 $4,500 $9,000


** No single family member will be subject to an out-of-pocket maximum greater than the employee only amount. Once two or more family members, depending on premium level, have met the out-of-pocket maximum, it will be met by all family members.

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Take Note!

• Deductibles and out-of-pocket maximums for in-network and out-of-network services add up separately

• Expenses over the MAC don’t count toward deductibles and out-of-pocket maximums

• Co-pays don’t count toward deductibles and out-of-pocket maximums

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Seeking Care Through Your PPO


Provider Network ✔ ✔

Choose any doctor ✔ ✔

No PCP selection required

✔ ✔

No PCP referrals ✔ ✔

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Who’s Eligible for the Partnership PPO?

• Anyone…

• …willing to make the Partnership Promise

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The Partnership Promise

• Know your health history

• Know your health risks

• Take steps to get and stay healthy

• Sign the State’s Partnership Promise

In return for making the Partnership Promise, your health insurance costs will be lower.

28

What’s Involved

• Health Questionnaire – age, diet, exercise and tobacco and alcohol use

• Health Screening – height, weight, blood sugar, blood pressure and cholesterol

• Routine preventive care – most in-network services covered at no cost

• Next steps depend on results – health coaching and programs to manage health risks

APS Healthcare will serve as the State’s health and wellness manager.

29

Completing Your Health Screening

• Based on any tests or screenings (e.g., through your regular annual physical) conducted after July 1, 2010

• You have until June 2011 to complete your health screening

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Managing Your Health Risks

• APS Healthcare works with you

• Evaluates health and health risks

• Recommends actions to reduce risks

• Provides individual coaching

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Keeping Your Promise

• Make the effort

• Follow recommendations of health and wellness manager

• Complete prescribed program

We encourage you to think about how your commitment to the Partnership Promise can improve your health. The ParTNers for Health

program is designed to support you.

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If You Cover Your Spouse

• Same PPO Option

• Your spouse must also sign a Partnership Promise

• Exception: If you and your spouse both work for a Participating Employer

• No Partnership Promise is required for covered children

33

Your Privacy

• Members’ personal health information is strictly confidential

• Written permission required in order for the State or employers to see any individual’s:» Health risk questionnaire responses

» Health screening results

» Participation in health and lifestyle management programs

Your health privacy rights are protected through a federal law called “HIPAA.”

34

Enrolling for Benefits

• It’s an “Open Enrollment” this year.

• All benefits-eligible employees can enroll themselves and their dependents to age 26

• If you and/or your spouse originally declined participation in the health plan when you were first eligible, you are considered to be a late applicant. If you choose to enroll now during open enrollment, a monthly late applicant fee will be charged until December 2013 in addition to the normal premium.

Monthly Late Applicant Fee

Employee Only $130

Spouse Only $143

Employee and Spouse $273

35

Special Considerations for Dependents

• Cover dependent child(ren) up to age 26

• Enroll eligible dependents for 2011 during the Open Enrollment period

• Dependents turning age 24 between July 1 and December 31, 2010, will not be cancelled from coveraged; current coverage continues through year-end

36

Verifying Your Dependents

• Information about verifying documentation will be in the Enrollment Kit.

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12-Month Pre-Existing Condition Exclusion

• The pre-existing condition exclusion applies to any employee or employee’s spouse who cannot show proof of prior creditable coverage but does not apply to any dependent children regardless of age.

• A pre-existing condition is a health problem that existed before your enrollment in a State-sponsored health insurance option• Applies to conditions you sought treatment or advice for in the past six

months• Coverage is not provided for services related to these conditions

• “Creditable coverage” from another health insurance plan can offset the length of the exclusion period

38

Pharmacy Benefits

• Caremark will continue to be the Pharmacy Benefits Manager for 2011.

• Customer Service: 1-877-522-TNRX (8679)

• Web: www.caremark.com

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Optional Dental

Prepaid Plan

• Fixed co-pays

• Participating dentists only

PDO Plan

• Any dentist

• Pay less with network providers

40

Accident and Life Insurance

• State provides $20,000 of term life and $40,000 of special accident insurance

• Additional optional coverage may be available for you and your family

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Making Your Choices

1. Health insurance option• Partnership OR Standard PPO• Insurance carrier• Premium Level• Enroll eligible dependents under

age 26

2. Dental coverage• Prepaid Dental OR PDO• Premium Level• Enroll eligible dependents under

age 26

3. Optional accident and life insurance• Purchase optional coverage for

yourself, your spouse or your eligible dependent child(ren)

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Completing Your Enrollment

• Your Enrollment Kit – includes Decision Guide, information DVD, premium sheet and enrollment forms• Mailed to current members in late August• Available to all eligible employees on request

• ParTNers for Health Call Center 1-866-741-6464 – available 24 hours, 7 days a week to answer questions

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Submitting Paper Forms

• Employees must meet the enrollment deadline: October 15, 2010

• Please write legibly and in ink. Verify you have listed all of your dependents.

• Completed forms must be returned to the following address:

Payroll OfficeP115 Andy Holt TowerKnoxville, TN 37996

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Online Enrollment through ESS

• Available to University employees as an alternative to paper forms

• Elect your health and dental insurance options

• Directions and userid/password will be mailed to your home address.

If you are adding dependents, you need to submit a paper enrollment form and applicable dependent eligibility verification.

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Take Note!

• Deductions begin in December 2010

• Coverage begins on January 1, 2011

• No changes until the next Annual Enrollment Transfer Period

Current members who do not complete enrollment will be enrolled in the Standard PPO.

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Member Communications

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Questions?

• Contact – [email protected]

• Call ParTNers for Health Call Center • Members: 1-866-741-6464

• Go online to www.partnersforhealthtn.gov

Preserving Our Health Benefits: Changes to Sustain Comprehensive, Affordable and Dependable...

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